Heirship. State of _________ ss County of _________ _________ being first duly sworn, on oath says: That he [she] was well acquainted with _________ in his [her] lifetime; that _________ died at the city of _________ state of _________ on _________ _________[date]. That _________ was married but once and then to _________; That _________ children were born of the marriage: _________ a son who died in the lifetime of _________ unmarried and without issue; _________ a son; and _________ a daughter, now the wife of _________. That at the time of his [her] death _________ left him [her] surviving his [her] [widow or widower], _________ his [her] son _________ and his [her] daughter _________ his [her] only heirs at law and next of kin. [Jurat] [Signature]